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% 1 year survival of Human Kidney Transplantation
_____1. Deceased-donor grafts
_____2. Living-donor grafts

1. 92%
2. 96%
Transplantation Kidney:
Average life expectancy of:
_____1. living-donor graft
_____2. deceased-donor graft
1. 20 years
2. 14 years
Expanded Criteria Donor
1. Deceased donor ___ years
2. Deceased donor more than 50 years and hypertension and Creatinine __mg/dL
3. Deceased donor more than 50 yrs and HTN and death by CVA
1. more than 60 yrs
2. more than 1.5

4. Deceased donor more than 50 yrs and death caused by CVA and crea more than 1.5mg/dL
The transplant procedure is relatively noninvasive, as the organ is placed in the ________ w/o entering the peritoneal cavity. Recipients without perioperative complications often can be discharged from hospital within __ days of the operation.
inguinal fossa
within 5 days
Current standard of care is that the candidate should have a life expectancy of __ yrs. to be put on a deceased organ with list.
5 years
impt. criterion for selection of donors for renal allografts?
HLA major histocompatibility complex
______1. A positive cytotoxic cross-match of recipient serum with donor T lymphocytes indicates the presence of preformed donor-specific anti-HLA class I antibodies and is usually predictive of an acute vasculitic event termed hyperacute rejection
Only absolute contraindication for kidney transplantation?
1. presensitization
2. ABO incompatibility
4 known sources of sensitization?
1. blood transfusion
2. prior transplant
3. pregnancy
4. vaccination/infection
Rejection that is mediated by lymphocytes that respond to HLA antigens expressed within the organ?
Cellular rejection
What lymphocyte responds to class II (HLA-DR) incompatibility by proliferating and releasing proinflammatory cytokines that augment the proliferative response of the immune system?
CD4+ lymphocyte
Lymphocyte precursors respond primarily to class I (HLA-A, -B) antigens and mature into cytotoxic effector cells that cause organ damage through contact and lysis of donor target cells?
CD 8+ cytotoxic lymphocyte
Binds cytosolic receptors and heat shock proteins. Blocks transcription of IL1, 2, 3, 6, TNF-a and IFNy
s/e: HTN. glucose intolerance, dyslipedemia, osteoporosis
Lipid-soluble polypeptide, trimolecular complex w/ cyclophilin and calcineurin block in cytokine (IL-2) production, however, stimulates TGF-B production.
s/e: hirsutism/hyperplasia of gums, nephrotoxicity, HTN, dyslipidemia
Macrolide, trimolecular complex w/ FKBP-12 and calcineurin block in cytokine (eg. IL2) productiob; may stimulate TGF B production.
s/e: nephrotoxicity, HTN, dyslipidemia, diabetes more likely
Mercaptopurine analogue, hepatic metabolites inhibit purine synthesis, marrow suppression (WBC>RBC>platelets)
Inhibit purine synthesis via inosine monophosphate dehydrogenase.
s/e: Diarrhea, cramps
dose related liver and marrow suppression is uncommon
Mycophenolate mofetil/sodium
Macrolide, complexes w/ FKBP-12 and then blocks p70 S6 kinase in the IL2 receptor pathway for proliferation
s/e: hyperlipidemia, thrombocytopenia
Sirolimus/ everolimus
Fusion protein, IV injections
-Binds CD80 and CD 86 prevents binding and T cell activation.
s/e: posttransplant lymphoproliferative disease
A depleting agent directed to the CD52 protein, widely distributed on immune cells such as B and T cells, natural killer cells, macrophages and some granulocytes
Azathioprine dose
1.5 - 2 mg/kg/day
In general:
1. ___-___mg prednisone given immediately before or at the time of transplantation, and the dose is reduce to 30mg w/in a week
2. For Tx of acute rejection, methylprednisolone, __-__g IV, is adm immed. upon Dx of beginning rejection and continued OD for 3 days

3. Maintenance dose of __-__mg/d are the rule
1. 200-300mg
2. 0.5-1g
3. 5-10mg/d
A major effect of steroids is preventing the release of ___ and ___ by monocyte-macrophages.
IL-6 and IL-1
an mTOR inhibitor, previously called rapamycin
procedure of choice in rejection episode to rule out urinary obstruction or to confirm the presence of perirenal collections of urine, blood or lymph.
Diagnostic Ultrasound
A late marker of rejection, but it may be the only sign
rise in serum creatinine level

other rarely char of rejection:
fever, swelling and tenderness over the allograft.
In rejection episode, failure to respond w/ methylprednisolone, 500-1000mg OD for 3 days is an indication of antibody therapy, usually with:_____
antithymocyte globulin
Rejection with antibody detected in recipient blood, the prognosis is poor, and aggressive use of:
_____1. anti-CD20 monoclonal antibody to target B lymphocytes
_____2. to target antibody-producing plasma cells
_____3. inhibit complement
1. retuximab
2. bortezomib
3. eculizumab
MC opportunistic infections in renal tp recipients.
4 Peritransplant (less than 1 mo.)
6 Early (1-6 mos.)
6 Late (more than 6 mos.)
Peritransplant- wound infections, Herpesvirus, Oral candidiasis, UTI

Early- Pneumocystis jiroveci, CMV, Legionella, Listeria, Hep B and C

Late- Aspergiluss, Nocardia, BK virus (polyoma), Herpes zoster, Hep B and C
The incidence of tumor in pts on immunosuppressive therapy is __-__% or app. 100x greater than that in the general population in the same age range
5 to 6 %
MC lesions in Renal tranplant pts
1. cancer of the skin and lips
2. carcinoma in situ of the cervix
3. lymphoma: Non-hodgkin
More than 50% of renal recipient mortality is attributable to:
Cardiovascular disease
In US, leading cause of ESRD is _______, accounting for 45% of newly diagnosed cases of ESRD.
Diabetes Mellitus
Deaths in ESRD are due mainly to:
___1. 40%
___2. 10%
1. cardiovascular dis.
2. infections
What law states that the larger the molecule, the slower is its rate of transfer across the membrane?

A small molecule such as urea, undergoes subtantial clearance, where as a larger molecule, such as creatinine is cleared efficiently.
Laws of diffusion
In addition to diffusive clearance, movement of waste products from the circulation into the dialysate may occur as a result of _________.
Occurs bec. of solvent drag with solutes being swept along w/ water across the semipermeable dialysis membrane.
Convective clearance
Is a plastic chamber with the ability to perfuse blood and dialysate compartments simultaneously at very high flow rates.

-are composed of bundles of capillary tubes through w/c blood circulates while dialysate travels on the outside of the fiber bundle.
Dialyzer are biocompatible synthetic membranes derived from _____ or related compounds (versus older cellulose \"bioincompatible\" membranes that activate the complement cascade.
___1. Potassium
___2. Calcium
___3. Sodium
1. 0 to 4 mmol/L
2. 1.25 mmol/L (2.5 meq/L)
3. 136- 140 mmol/L
What is used in pt. who freq. develop hypotension during their dialysis run to counterbalance urea-related osmolar gradient?

Sodium modeling
-dialysate Na is gradually lowered from the range of 145-155 mmol/L to isotonic conc. (135-140 mmol/L) near the end of the dialysis Tx, typically declining either in steps or in linear or exponential fashion.
Blood pump moves blood from the access site, through the dialyzer and back to the patient. The blood flow rate may range from ____ to ____ ml/min. depending on the type and integrity of the vascular access.
250-500 mL/min
What fistula in which the cephalic vein is anastomosed end-to-side to the radial artery results in arterialization of the vein?
Brescia-Cimino fistula
Although fistulas have the highest long-term patency rate of all dialysis access options
Many pts undergo placement of an AV graft (ie, the interposition of prosthetic material, usually ________, bet. an artery and a vein)
The most impt. complication of AV graft is ____ due principally to intimal hyperplasia at the anastomosis bet. the graft and recipient vein.
thrombosis of the graft

and graft failure
For persons on maintenance hemodialysis, ________ are often used when arteriovenous fistulas and grafts have failed or are not feasible due to anatomic considerations.
tunneled catheters
Most tunneled catheters are placed in the:
1. internal jugular veins
2. external jugular
3. femoral- infection rates may be higher
4. subclavian veins - stenoses
HD procedure consists of pumping heparinized blood through the dialyzer at a flow rate of __-__ ml/min while dialysate flows in opposite counter-current direction at __-__ ml/min.
300-500 ml/min

500-800 ml/min
Although the fractional removal of urea nitrogen- considered to be the standard methods by which adequacy of dialysis is measured, a large multicenter rct: ____ study failed to show a difference in mortality assoc. w/ a large difference in urea clearance
HEMO study
Current targets
Urea reduction( BUN per HD session) of more than __-__% and a body water-indexed clearance x time product (KT/V) above __ or __depending on whether urea conc. are equilibrated

1.2 or 1.05
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